In parallel to organising our May symposium, we’re also preparing our 2017 report that will describe the field of practice that is bridging health systems and local communities. The report will be an update of our 2016 report, and will include a list of over-arching principles that we have observed across the many innovators in the field.
Two of the plenary speakers at our forthcoming symposium agreed to write Forewords for the report, and today we’re sharing one of them.
S Leonard Syme is Professor Emeritus of Epidemiology and Community Health at Berkeley School of Public Health. His Foreword is below. At the symposium, he’ll be in ‘a candid conversation about failure’ with Carl Baty, Executive Director of Rounding The Bases. We’ll hear from Carl next week.
It is always awkward to describe your life’s work as a failure. On the other hand, if that admission will help to make the world a better place, it is perhaps worth the embarrassment.
I have been doing research on the social determinants of health for almost 60 years. All went well until I began moving away from the simple description of social risk factors to applying that knowledge.
In the early 1970’s, we began the Multiple Risk Factor Intervention Trial (MRFIT), a US study to see if we could lower the rate of coronary heart disease among American men aged 35-57. The approach was soundly based on risk factor data showing that men had much higher rates of heart disease if they had high blood cholesterol, high blood pressure and if they smoked cigarettes.
We screened 356,222 men in 22 cities. 12,866 were eventually chosen and randomly divided into one group that received an intensive intervention of dietary advice for lowering blood cholesterol, treatment for high blood pressure, and counseling to stop cigarette smoking, and one group that was referred back to their doctors for the usual care at the time.
We did this for seven years at a cost (then) of $180,000,000. The difference in deaths from coronary heart disease between the two groups was statistically non-significant.
That was my introduction to the world of trying to apply knowledge from epidemiologic research. Since that time, many of my colleagues and I have tried repeatedly to intervene in high-risk populations to lower rates of disease, and we have all failed.
In today’s money, MRFIT cost about $555,000,000. And it’s important to remember that it was just one study from one group of researchers. Granted, it was big, national, and long, but it still was only one study. Imagine the cost of all of the studies over the last 40 years, valiant efforts though they all were.
I now offer a course at the Graduate School of Public Health in Berkeley called Public Health Interventions. My colleague and I introduce students to this problem, including its scale and our repeated failures. We invite them to design new interventions but with one rule: nothing normal.
Our course is based on our conviction that we ‘experts’ in public health have it wrong. Although we have important messages for people, they have their lives to lead. The two often do not coincide. We need a new kind of expert, one that can respond to the real issues in the lives of the people we are trying to reach.
It is with real pleasure, then, that I welcome (the forthcoming) report. Here is one the few efforts to really think through the challenges we face, to urge a dialogue on this issue, and to honestly face up to the magnitude of our problem.
Perhaps my failures can be of help after all.